What is the approach to a middle-aged to elderly woman, possibly with obesity, hypertension, or diabetes, presenting with a partially empty sella turcica (a condition where the sella turcica appears empty or partially filled with cerebrospinal fluid) without a visible mass on imaging?

Management of Partially Empty Sella Without Mass

All patients with partially empty sella require comprehensive hormonal screening regardless of symptoms, as hormonal deficiencies occur in 30-52% of cases, and should be referred to endocrinology if any abnormalities are detected. 1, 2

Immediate Clinical Assessment

Evaluate for specific red flag symptoms that require urgent workup:

• Visual symptoms (field defects, declining acuity) indicating possible optic chiasm compression 1
• Signs of increased intracranial pressure (papilledema, pulsatile tinnitus, specific headache patterns) suggesting idiopathic intracranial hypertension (IIH), particularly in obese women with hypertension 1
• Hormonal deficiency symptoms (fatigue, cold intolerance, sexual dysfunction) 3
• CSF rhinorrhea requiring urgent evaluation 1

Critical pitfall: Do not attribute headache directly to the empty sella finding—it is typically incidental and unrelated to headache symptoms. 1, 3

Mandatory Hormonal Screening Panel

Obtain comprehensive hormonal evaluation in all patients, even if asymptomatic:

• Thyroid axis: TSH, free T4, T3 (deficiencies in up to 48% of cases) 3
• Adrenal axis: Morning cortisol and ACTH 3
• Gonadal axis: Estradiol or testosterone 3, 2
• Prolactin: Elevated in approximately 28% of cases 3
• Growth hormone axis: IGF-1 3, 2

The rationale is compelling: affected-axis rates often exceed 10% and may reach 50%, with pooled analyses showing 52% prevalence of pituitary insufficiency in patients with primary empty sella syndrome. 1, 2

Imaging Confirmation

• MRI with high-resolution pituitary protocols is the gold standard and preferred modality for confirming diagnosis and excluding other pathology 1, 4
• No additional urgent imaging is needed if MRI already demonstrates partially empty sella without concerning features 1, 3
• CT has limited utility and is fundamentally inadequate compared to MRI for detecting pituitary pathology 1, 4

Specialist Referrals

Endocrinology referral is indicated if:

• Any hormonal abnormalities detected on screening 1, 3
• Symptoms suggestive of pituitary dysfunction present 3

Ophthalmology referral is indicated if:

• Visual symptoms present 1, 3
• Concerns about increased intracranial pressure 1, 3
• Optic chiasm compression noted on imaging 1, 3
• Formal assessment for papilledema needed 5

Special Consideration: Idiopathic Intracranial Hypertension

Do not overlook IIH in patients presenting with headache and partially empty sella, as this represents a distinct clinical entity requiring specific management. 1

• Partially empty sella is a typical neuroimaging feature of raised intracranial pressure, particularly in obese women with hypertension and diabetes 1
• Primary treatment for IIH-associated empty sella is weight loss with referral to weight management programs 1
• Surgical CSF diversion is reserved only for imminent visual loss 1

What NOT to Do

• Do not order unnecessary urgent tests or interventions that won't change immediate management in asymptomatic patients with confirmed partially empty sella on MRI 1, 3
• Do not skip hormonal screening based on absence of symptoms—most patients with hypopituitarism remain asymptomatic initially 1, 2
• Do not use CT instead of MRI for characterization of sellar pathology 1, 4